Do artificial sweeteners increase risk of cardiovascular diseases?

Excessive added sugar consumption is recognised as a major risk factor by public health authorities. The World Health Organization (WHO), for example, recommends that less than 5% of daily energy intake should come from free sugars.

Artificial sweeteners have proved a popular alternative. According to Market Data Forecast, the artificial sweetener market is currently valued at €7bn and expected to grow to €9.7bn by 2028.

It is perhaps then unsurprising to learn that more than 23,000 products worldwide contain artificial sweeteners. Present in ‘ultra-processed’ foods such as artificially sweetened beverages, low and no calorie sugar alternatives are also directly used by consumers as table top sweeteners.

At the same time, cardiovascular diseases (CVDs) continue to pose serious health risks. CVDs are the leading cause of death worldwide.

Past studies have sought to identify a link between CVD risk and artificial sweetener intake, predominantly focusing on intake of soft drinks containing artificial sweeteners. But researchers in France want to get a clearer picture of all artificial sweeteners in all applications, and not just in beverages.

In a new study published in The BMJ​, researchers have investigated associations between consumption of artificial sweeteners from all dietary sources (from beverages to table top sweeteners, and dairy products), by type (aspartame, acesulfame potassium, and sucralose), and risk of CVD (overall, coronary, and cerebrovascular).

Who consumes artificial sweeteners? And how much?​

The new study was performed within the population based NutriNet-Santé cohort. A total of 102,228 French adult participants were selected, who had submitted their dietary records online. Follow-up biannual health questionnaires and a personal health interface allowed participants to report any new health events, including CVD events.

Findings revealed 37.1% of participants consumed artificial sweeteners, with the average intake of artificial sweeteners calculated at 42.46% among consumers – corresponding to either one individual packet of tabletop sweetener or 100ml of diet soda.

Higher consumers tended to be younger with a higher body mass index, were more likely to smoke and be less physically active. They also tended to have higher intake of sodium, red and processed meat, dairy products, and beverages with no added sugar.

Soft drinks with no added sugar accounted for 53% of artificial sweeteners, but tabletop sweeteners were also a significant percentage at 30%. Artificially sweetened flavoured dairy products, such as yoghurts and cottage cheese, accounted for 8%.

Linking artificial sweeteners to CVD risk​

A link between artificial sweetener intake and CVD risk was identified. “In the NutriNet-Santé cohort, total artificial sweetener intake was associate with increased risk of overall CVD and cerebrovascular disease,”​ noted the study authors.

Aspartame intake was associated with increased risk of cerebrovascular events, and acesulfame potassium and sucralose were associated with increased coronary heart disease risk.

“Our results suggest no benefit from substituting artificial sweeteners for added sugar on CVD outcomes.”​

Industry does not agree, however. The International Sweeteners Association (ISA) – whose members include Mars Wrigley and PepsiCo Inc. – has spoken out against the findings, arguing that contrary to its claims, there is “no causal evidence that low/no calorie sweeteners could increase the risk of CVDs”. ​

‘Observational studies cannot establish a cause-and-effect relationship’​

While the study claims to show an association between low/no calorie sweeteners intake and CVD risk, the ISA stressed there is no evidence of a ‘plausible mechanism’ to support potential effects of low/no calorie sweeteners on cardiometabolic health.

“The safety of all approved low/no calorie sweeteners has been confirmed by food safety bodies worldwide including the Joint Expert Committee on Food Additives of the UN FAO and the WHO, the EFSA, and the US FDA.”​

The ISA takes particular interest in the quantities of sweeteners the French cohort was consuming, which it described as ‘extremely low’, even for the ‘high consumers’.

“Importantly, experts have questioned the ability to detect an association between low/no calorie sweeteners at such low levels of intake and any health outcome and stressed that, in such circumstances, confounding factors become more influential.​

“By design, observational studies cannot establish a cause-and-effect relationship due to their observational nature and the inability to exclude residual confounding or, importantly, attenuate the effects of reverse causality.”​

Industry also takes issue with the researchers’ conclusion, which suggested there is ‘no benefit’ in substituting artificial sweeteners for added sugar on CVOD outcomes.

“At a time when non-communicable diseases, including diabetes and dental diseases, remain major global health challenges, and in light of current public health recommendations to reduce overall sugar intake, low/no calorie sweeteners can be helpful in creating healthier food environments,” ​noted an ISA spokesperson.

“They provide people with a wide choice of sweet-tasting options with low or no calories, and thus can be a useful tool, when used in place of sugar and as part of a balanced diet, in helping reduce overall sugar and calorie intake, as well as in managing blood glucose levels.”​

WHO: New recommendations question value of low/no calorie sweeteners​

This latest study is not the first-time non-sugar sweeteners have been associated with health concerns this year.

In July, new recommendations from the WHO​ questioned the value of low/no calorie sweeteners such as stevia, sucralose, aspartame, stevia and monk fruit, in a healthy diet.

According to a draft guideline, the WHO suggested non-sugar sweeteners not be used as a means of achieving weight control or reducing risk of non-communicable diseases.

The guideline does not apply to people living with diabetes.

“The lack of evidence to suggest that non-sugar sweetener use is beneficial for body weight or other measures of body fatness over the long term together with possible long-term undesirable effects in the form of increased risk of death and disease, outweighed any potential short-term health effects resulting from the relatively small reductions in body weight and BMI observed in randomised controlled trials,” ​noted the WHO.

The ISA also weighed in at the time: “Failing to recognise the role of low/no calorie sweeteners in sugar and energy reduction, and ultimately in weight management is a disservice to public health.”​

ISA chairman Robert Peterson added: “Governments around the world are trying to tackle the serious problem of rising rates of obesity and diabetes. Not to mention dental diseases…It is a pity that the well-established benefit of non-sugar sweeteners used in dental health has not been recognised.”​

Source: The BMJ​
‘Artificial sweeteners and risk of cardiovascular diseases: results from the prospective NutriNet-Santé cohort
Published 7 September 2022
DOI: https://doi.org/10.1136/bmj-2022-071204
Authors: Charlotte Debras, Eloi Chazelas, Laury Sellem et al.